Classification of Porcine Cranial Fracture Patterns Using a Fracture Printing Interface,,

Distinguishing between accidental and abusive head trauma in children can be difficult, as there is a lack of baseline data for pediatric cranial fracture patterns. A porcine head model has recently been developed and utilized in a series of studies to investigate the effects of impact energy level, surface type, and constraint condition on cranial fracture patterns. In the current study, an automated pattern recognition method, or a fracture printing interface (FPI), was developed to classify cranial fracture patterns that were associated with different impact scenarios documented in previous experiments. The FPI accurately predicted the energy level when the impact surface type was rigid. Additionally, the FPI was exceedingly successful in determining fractures caused by skulls being dropped with a high‐level energy (97% accuracy). The FPI, currently developed on the porcine data, may in the future be transformed to the task of cranial fracture pattern classification for human infant skulls.     

A Unique Type of Birth Trauma Mistaken for Abuse

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction‐related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.     

Case report: Forensic anthropological assessment in a suspected case of child abuse from South Africa

Not many case reports of suspected child abuse as assessed solely on skeletal remains are available. Forensic anthropologists have intimate knowledge of normal skeletal anatomy, bone trauma and processes of healing of bone and may therefore be of help in suspected cases of child abuse. Patterns of trauma in juvenile skeletal remains which are suggestive of abuse include fractures in different phases of healing, multiple fractures, typical fractures on ribs and long bones and severe, complicated cranial fractures. The aim of this paper is to report on the findings of the analysis of the skeletal remains of a 3.5 years old boy. Forensic pathological examination indicated that the boy had died from a massive cranial fracture, with multiple injuries present to the rest of the body. After the body had been buried for some time, it was exhumed and we were requested to look for signs of chronic, long-term abuse. Findings included a massive cranial fracture, another fracture in the roof of the orbit, two areas of non-specific subperiosteal bone growth and several untreated carious teeth. No clear healed fracture could be found, except for a possible healed cranial base fracture which stretched transversely across the petrosal bone. This area showed signs of recent bone activity. The court decided that this was not enough evidence of chronic abuse and found the accused guilty of murder but not of chronic child abuse. This case illustrates the difficulty to obtain clear signs of chronic injury on juvenile remains.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Punched with a fist: the etiology of a fatal depressed cranial fracture

We report a case in which a 33-year-old man was discovered unconscious following a fistfight with another man. Emergency neurosurgical efforts to repair a depressed temporoparietal skull fracture and associated brain injuries were unsuccessful. The forensic anthropologist and pathologist worked in tandem to sort out a complex combination of cranial evidence, including healed antemortem trauma, perimortem blunt force trauma, remote and recent neurosurgical intervention, and the craniotomy cut performed at autopsy. The victim had suffered head injuries and a right temporoparietal craniotomy ten years prior to death. The perimortem cranial fractures were centrally located within a surgically repaired roundel of bone involving portions of the right temporal and parietal bones. Reportedly, the victim was punched on the right side of his head as he was lying on the ground with the left side of his head against an asphalt surface. A primary question in the case was whether a blow with a fist could have produced the observed cranial injuries. To adequately answer that question, known data on the minimum amount of force required to fracture the temporoparietal region were compared to data on the amount of force generated by a blow with a fist. A biomechanics expert demonstrated that a single blow with a fist to the rigidly supported head of the victim could generate the required force to produce the observed fractures. The previous medical condition possibly predisposed the victim to the cranial fractures and contributed to the depressed nature of the fractures. Although depressed cranial fractures do not typically result from a blow with a fist, it was determined in this case that the fracture pattern was consistent with a punch to the head.     

Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report,Biomechanical Considerations,and Review of the Literature

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.     

Characterization and Comparison of Injuries Caused by Accidental and Non‐accidental Blunt Force Trauma in Dogs and Cats

Motor vehicle accidents (MVA) are often difficult to distinguish from non‐accidental injury (NAI). This retrospective case–control study compared animals with known MVA trauma against those with known NAI. Medical records of 426 dogs and cats treated after MVA and 50 after NAI were evaluated. Injuries significantly associated with MVA were pelvic fractures, pneumothorax, pulmonary contusion, abrasions, and degloving wounds. Injuries associated with NAI were fractures of the skull, teeth, vertebrae, and ribs, scleral hemorrhage, damage to claws, and evidence of older fractures. Odds ratios are reported for these injuries. MVA rib fractures were found to occur in clusters on one side of the body, with cranial ribs more likely to fracture, while NAI rib fractures were found to occur bilaterally with no cranial–caudal pattern. Establishing evidence‐based patterns of injury may help clinicians differentiate causes of trauma and may aid in the documentation and prosecution of animal abuse.     

A case of traumatic osteomyelitis in a victim of child abuse

A premature black female infant born at 31 weeks gestation with history of 4 weeks in the newborn intensive care unit was discharged healthy to the care of her mother and was lost to follow-up. At age 4 months the infant was found dead in bed. There was no history of trauma and no external injuries were noted. There was no attempt at resuscitation. Coroner's autopsy showed acute bronchopneumonia, 3 partially healed skull fractures, a chronic subdural hematoma, chronic intracerebral hemorrhage, retinal hemorrhages, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess of the bone surrounded by scar tissue and containing pus and granulation tissue. We believe this inflicted fracture became secondarily infected by a hematogenous route. The final diagnosis of the cause of death was pneumonia secondary to multiple blunt force trauma, and the manner of death was diagnosed as homicidal. This is believed to be the first reported case of osteomyelitis in a context of child abuse.     

Blunt force cranial trauma in the Cambodian killing fields

In this paper we present a unique pattern of blunt force cranial trauma that was observed in 10 of a sample of 85 crania from a Cambodian skeletal collection comprised of Khmer Rouge victims. Initial examination of the trauma, which presents as substantial damage to the occipital with fractures extending to the cranial base, suggested the pattern was classifiable as a basilar or ring fracture. However, further investigation, including trauma analysis and historical research, revealed that this fracture type is distinctive from basilar and ring fractures. Historical data indicate that a particular execution method was the likely source of the trauma. Recognition of this trauma pattern is significant because it exemplifies the distinct fracture configuration resulting from an apparently categorical and methodical execution technique. Identification of this fracture type could potentially assist forensic investigators in the recognition of specific methods of murder or execution.     

Can Birth Trauma Be Confused for Abuse?

Abstract: An unexpected infant death is usually investigated with a complete autopsy. If evidence of prior trauma is found at autopsy in these cases, suspicion is raised for nonaccidental trauma. In a young infant, the residua of trauma received during birth has the potential to be incorrectly interpreted as nonaccidental trauma. We report a the findings of a 4 1/2‐month‐old‐infant that died unexpectedly with a healing linear skull fracture and a circular lesion over the calvarium found at autopsy. Though this lesion was concerning, the remainder of the autopsy and the histological findings did not support a diagnosis of recent trauma. Review of the literature describing birth injuries made the diagnosis of healing, residual birth trauma more convincing in this case.     

Characteristics and Prediction of Cranial Crush Injuries in Children*†

Abstract: This study documents four clinical cases of fatal crush injuries to children between 1.5 and 6 years of age with correlations between modeled stress and clinically observed fracture patterns. The clinical case fractures were concentrated in the basicranium, bridged the impact sites, and traversed the middle cranial fossa in the area of the spheno‐occipital synchondrosis. The crushing forces from these cases were recreated on a simplified finite element model of a cranium by applying bilateral pressures to corresponding regions. Numerous trials were run to develop a representative pattern of principal stress directions. In all cases, the highest tensile stresses were located on the basicranium and corresponded to the observed fracture path(s). These results suggest that prefailure stress field diagrams may predict fracture propagation paths, although these will not be exact. Also, these analyses indicate that quasi‐static bilateral loading of the cranium may lead to predictable fracture of the basicranium.     

Recognition of Skeletal Fractures in Infants: An Autopsy Technique

Abstract:  Complete recognition and documentation of injury pattern is crucial in the diagnosis of child abuse. Skeletal fractures regarded as highly specific to nonaccidental injury in infants include posterior rib, scapular, metaphyseal, and spinous process fractures. These injuries are often occult, especially when acute, to standard radiologic and autopsy procedures. The presented autopsy technique requires incising and reflecting skeletal muscles to expose the bones and costal osseous joints in situ , increasing the opportunity to recognize skeletal injury. Fractured or atypical appearing bones are removed and processed for complete evaluation. The bones are processed by macerating the soft tissue in a water soap bath at an elevated temperature. To aid in reconstruction of the decedent, long bones are replaced with wooden dowels and the chest cavity is packed with the organ bag. The technique is invasive and recommended for cases in which the pathologist has reasonable suspicion of acute or remote trauma.     

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.     

Fatal non-accidental pediatric cranial fracture risk and three-layered cranial architecture development

This study examines the influence of three-layered cranial architecture development upon blunt force trauma (BFT) cranial outcomes associated with pediatric non-accidental injury (NAI). Macroscopic and microscopic metric and morphological comparisons of subadult crania ranging from perinatal to 17 years of age chronicle the ontogenetic development and spatial and temporal variability in the emergence of a mature cranial architecture. Cranial vault thickness increases with subadult age, accelerating in the first 2 years of life due to rapid brain growth during this period. Three-layer differentiation of the cranial tables and diploë initiates by 3–6 months but is not consistently observed until 18 months to 2 years; diploë formation is not well developed until after age 4 and does not manifest a mature appearance until after age 8. These results allow topographic documentation of cortical and diploic development and temporal and spatial variability across the growing cranium. The lateral cranial vault is identified as expressing delayed development and reduced expression of the three-layer architecture, a pattern that continues into adulthood. Comparison of fracture locations from known BFT pediatric cases with identified cranial fracture high-risk impact regions shows a concordance and suggests the presence of a higher fracture risk associated with non-accidental BFT in the lateral vault region in subadults below the age of 2. The absence or lesser development of a three-layered architecture in subadults leaves their cranial bones, particularly in the lateral vault, thin and vulnerable to the effects of BFT.     

Bilateral First Rib Anomalous Articulations with Pseudarthroses Mimicking Healing Fractures in an Infant with Abusive Head Injury

Bilateral symmetric bone nodules were observed in the anterolateral first ribs of an infant with shaking injuries at autopsy. The location prompted diagnostic considerations of healing fractures versus anomalous articulations with pseudarthroses. The forensic pathologist worked with forensic anthropologists and pediatric radiologists to evaluate autopsy findings and compare premortem and postmortem X‐rays. Gross examination of the bones by the pathologist and anthropologists confirmed bilateral, callus‐like bone nodules in first‐rib locations associated with pseudarthroses. Histologic examination of one of the bones further showed features most consistent with pseudarthrosis, not a healing fracture. Radiologists then compared multiple premortem and postmortem radiographs that showed no remodeling of the bone over a 2‐week interval between the time of injury and death, which would be unexpected for a healing fracture in an infant. This multidisciplinary approach resulted in the appropriate diagnosis of pseudarthroses due to anomalous articulations, an uncommon finding in forensic pathology.     

The Role of Interface on the Impact Characteristics and Cranial Fracture Patterns Using the Immature Porcine Head Model

The role of impact interface characteristics on the biomechanics and patterns of cranial fracture has not been investigated in detail, and especially for the pediatric head. In this study, infant porcine skulls aged 2–19 days were dropped with an energy to cause fracturing onto four surfaces varying in stiffness from a rigid plate to one covered with plush carpeting. Results showed that heads dropped onto the rigid surface produced more extensive cranial fracturing than onto carpeted surfaces. Contact forces generated at fracture initiation and the overall maximum contact forces were generally lower for the rigid than carpeted impacts. While the degree of cranial fracturing from impacts onto the heavy carpeted surface was comparable to that of lower‐energy rigid surface impacts, there were fewer diastatic fractures. This suggests that characteristics of the cranial fracture patterns may be used to differentiate energy level from impact interface in pediatric forensic cases.     

不同部位颅脑摔跌伤的特征分析68例

目的探讨不同受力部位颅脑摔跌伤后损伤程度和特征差异。方法收集摔跌所致颅脑损伤68例,根据案情、受伤过程、临床体征、CT影像资料将受伤部位分为颅前部、颅侧部、颅后部;损伤类型分为颅骨骨折、硬脑膜外血肿、硬脑膜下血肿和脑挫裂伤;损伤数量分为单一和多发伤;颅骨骨折分为受力点骨折和非受力点骨折;脑挫裂伤分为冲击伤、对冲伤等。运用非参数统计χ2检验比较其频数分布。结果不同摔跌部位颅骨骨折和颅脑损伤程度存在明显差异(P0.05),颅后部摔跌颅骨骨折远离受力点多见,多发伤为主,而颅前部、颅侧部受力点骨折多见,单处损伤多见;颅后部、颅侧部摔跌后脑挫裂伤发生率高,以对冲部位多见,颅前部摔跌后脑挫裂伤发生率低,冲击伤亦多见。结论摔跌部位不同颅脑损伤程度和特征存在差异,CT检查资料有助于损伤机制推断。     

Inadvertent clavicular fractures caused by "chiropractic" manipulations in an infant: an unusual form of pseudoabuse

A nine-month-old child was found unresponsive in his crib, five hours after his last feeding. At autopsy, there were no external or internal signs of abuse or neglect, and a few visceral pleural and epicardial petechiae were consistent with the sudden infant death syndrome (SIDS). However, postmortem total body radiographs revealed healing, symmetrical clavicular fractures and a healing left medial humeral epicondyle fracture. The parents had no explanation for these injuries and denied causing any harm to the child. The location and nature of the fractures strongly suggested abusive origin, and the case was reported to the police and the district attorney's office as child abuse. During the investigation, information from the parents indicated that the child had undergone "chiropractic" manipulations by an unlicensed therapist, between three and four weeks prior to death, to correct supposed "shoulder dislocations." This time interval correlated with the histologic age of the injuries, and the history explained their unusual bilateral location and appearance. The parents were exonerated of abuse charges, and the death was ascribed to SIDS.     

The Role of Interface Shape on the Impact Characteristics and Cranial Fracture Patterns Using the Immature Porcine Head Model, ,

The forensic literature suggests that when adolescents fall onto edged and pointed surfaces, depressed fractures can occur at low energy levels. This study documents impact biomechanics and fracture characteristics of infant porcine skulls dropped onto flat, curved, edged, and focal surfaces. Results showed that the energy needed for fracture initiation was nearly four times higher against a flat surface than against the other surfaces. While characteristic measures of fracture such as number and length of fractures did not vary with impact surface shape, the fracture patterns did depend on impact surface shape. While experimental impacts against the flat surface produced linear fractures initiating at sutural boundaries peripheral to the point of impact (POI), more focal impacts produced depressed fractures initiating at the POI. The study supported case‐based forensic literature suggesting cranial fracture patterns depend on impact surface shape and that fracture initiation energy is lower for more focal impacts.     

不同年龄组颅脑损伤CT扫描分析

本文对520例不同年龄组的颅脑损伤CT片进行了观察分析，表明青少年损伤原因以高坠多见，损伤类型以颅骨凹陷骨折及硬膜外血肿多见，老年组损伤原因以头部击伤多见，损伤类型以颅骨骨折、硬膜下血肿、脑多发性挫裂伤及脑多发性血肿多见，成年组介于两者之间。